Key messages
• Case management programmes for older people living with frailty in the community may make little or no difference to patient and service outcomes and care-related costs.
• There is insufficient evidence to warrant any current change in practice.
• Futures trials are needed to determine which elements of these programmes benefit different people.
Why is this review important?
The number of people living with frailty aged 65 years and older is increasing around the world. There is no standard definition of frailty, but broadly speaking, frailty is an age-related reduced ability to recover quickly following a health problem, which can then have a significant impact on the person's everyday activities. People living with frailty are at high risk of declines in health and well-being, and often experience poorly co-ordinated health and care services. Integrated care aims to improve co-ordination of services and patient outcomes and is being widely implemented in the UK and internationally. Case management is one type of community-based integrated care programme. These programmes are delivered by a health or social care professional, supported by a wider team, and include assessment, care planning, and co-ordination of care to meet the needs of the individual. No reviews have looked at whether case management improves patient and service outcomes and reduces costs in people aged 65 years and older living with frailty, compared with standard care (usually involving management of care with a general practitioner). We conducted this review to address that gap.
What did we want to find out?
We wanted to find out if case management programmes are better than standard care for improving mortality, nursing home admission, quality of life, complications (medical event or injury that arose as a consequence of taking part in the trial), physical function, hospital admission, and costs.
What did we do?
We searched the scientific literature for randomised controlled trials, in which participants were randomly assigned to receive either the case management programme or standard care.
What did we find?
We found 20 relevant trials conducted in high-income countries in Europe, North America, Asia, and Oceania. This represented 11,860 people living with frailty.
Key results
• Mortality
The evidence is based on 14 trials with 9924 participants. Case management programmes compared to standard care may result in little or no difference in mortality after 12 months.
• Nursing home admission
The evidence is based on four trials with 1108 participants. Case management programmes compared to standard care may result in little or no difference in nursing home admission after 12 months.
• Quality of life
The evidence is based on 11 trials with 9284 participants. Case management programmes compared to standard care may result in little or no difference in quality of life after three to 24 months.
• Complications
The evidence is based on two trials with 592 participants. Case management programmes compared to standard care may result in little or no difference in complications after 12 to 24 months.
• Change in physical function
The evidence is based on 16 trials with 10,652 participants. Case management programmes compared to standard care may result in little or no difference in physical function after three to 24 months.
• Hospital admission
The evidence is based on five trials with 2424 participants. Case management programmes compared to standard care probably result in little or no difference in hospital admission after 12 months.
• Change in costs
The evidence is based on 14 trials with 8486 participants. Case management programmes compared to standard care probably result in little or no difference in change in costs (including healthcare service costs, intervention costs, and other costs such as informal care) after six to 36 months.
Main limitations of this review
We have little confidence in the evidence on mortality, nursing home admission, quality of life, complications, and change in physical function, and we are moderately confident in the evidence on change in healthcare utilisation and change in costs. Issues that reduced our confidence in the evidence included substantial variation between trials in the number of people enrolled, the definition of frailty, the setting of case management programmes, the care providers involved, and the time point of outcome measurement.
How up-to-date is this review?
The review authors searched for trials up to 23 September 2022.
We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.
Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems.
To assess the effects of case management for integrated care of older people living with frailty compared with usual care.
We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts.
We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty.
We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence.
We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate.
Case management compared to standard care may result in little or no difference in the following outcomes.
• Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence)
• Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence)
• Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from −6.32 points (95% CI −11.04 to −1.59) to 6.1 points (95% CI −3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence)
• Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence)
• Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from −0.12 points (95% CI −0.93 to 0.68) to 3.4 points (95% CI −2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence)
Case management compared to standard care probably results in little or no difference in the following outcomes.
• Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence)
• Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care.